Provider Demographics
NPI:1992850432
Name:ANDOVER SENIOR CARE, LLC
Entity Type:Organization
Organization Name:ANDOVER SENIOR CARE, LLC
Other - Org Name:VICTORIA FALLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:F
Authorized Official - Last Name:LAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-733-2645
Mailing Address - Street 1:408 E CENTRAL AVE
Mailing Address - Street 2:PO BOX 906
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-8556
Mailing Address - Country:US
Mailing Address - Phone:316-733-0334
Mailing Address - Fax:316-733-0995
Practice Address - Street 1:408 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-8556
Practice Address - Country:US
Practice Address - Phone:316-733-0334
Practice Address - Fax:316-733-0995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN-008011310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility